Medical Office Survey on Patient Safety Culture Comparative Database

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form Form #4 Example Screen Shots of Web Site Information Collection	Form	New	Available
Form Form #3 Medical Office Information Form	Form	New	Available
Form Form #2 Medical Office SOPS Database Data Use Agreement	Form and Instruction	New	Available
Form Form #1 Medical Office SOPS Database Eligibility Form	Form	New	Repair queued
Supporting Statement Part B -- MOSOPS Comparative Database 5-15-2012.doc	Supporting Statement B	Uploaded 2012-05-29	Available
Attachment H - TEP lists.doc	Supplementary Document	Uploaded 2012-02-09	Available
Attachment G - MO Expert Review Panel Members.doc	Supplementary Document	Uploaded 2012-02-09	Available
Attachment E - Sample Individual MO Feedback Report.pdf	Supplementary Document	Uploaded 2012-02-09	Available
Attachment A - MO SOPS questionnaire.doc	Supplementary Document	Uploaded 2012-02-09	Available
Attachment K - MO Data File Specs.pdf	Supplementary Document	Uploaded 2012-02-09	Available
Attachment I - Emails - MO SOPS Data Submission.doc	Supplementary Document	Uploaded 2012-02-09	Available
Supporting Statement Part A -- MOSOPS Comparative Database 5-15-2012.doc	Supporting Statement A	Uploaded 2012-05-29	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
201169	Data Submission	Form	New	Example Screen Shots of Web Site Information Collection
201168	Medical Office Information Form	Form	New	Medical Office Information Form
201167	Data Use Agreement	Form and Instruction	New	Medical Office SOPS Database Data Use Agreement
201166	Eligibility Form	Form	New	Medical Office SOPS Database Eligibility Form

ICR Details

OMB Control No: 0935-0196	ICR Reference No: 201202-0935-005
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/AHRQ	Agency Tracking No:
Title: Medical Office Survey on Patient Safety Culture Comparative Database
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 06/08/2012
Retrieve Notice of Action (NOA)	Date Received in OIRA: 02/13/2012
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2015	36 Months From Approved
Responses	1,950	0	0
Time Burden (Hours)	816	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The Agency for Healthcare Research and Quality (AHRQ) requests that the Office of Management and Budget (OMB) approve, under the Paperwork Reduction Act of 1995, AHRQ's collection of information for the AHRQ Medical Office Survey on Patient Safety Culture (Medical Office SOPS) Comparative Database. The Medical Office SOPS Comparative Database consists of data from the AHRQ Medical Office Survey on Patient Safety Culture. Medical offices in the U.S. are asked to voluntarily submit data from the survey to AHRQ, through its contractor, Westat. The Medical Office SOPS Database is modeled after the Hospital SOPS Database [OMB NO. 0935-0162; approved 05/04/2010] that was originally developed by AHRQ in 2006 in response to requests from hospitals interested in knowing how their patient safety culture survey results compare to those of other hospitals.

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Authorizing Statute(s): US Code: 42 USC 299 Name of Law: Healthcare Research and Quality Act of 1999
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 72929	11/28/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 5023	02/01/2012
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 4

table that charts list of burden

IC Title	Form No.	Form Name
Data Submission	Form #4	Example Screen Shots of Web Site Information Collection
Data Use Agreement	Form #2	Medical Office SOPS Database Data Use Agreement
Eligibility Form	Form #1	Medical Office SOPS Database Eligibility Form
Medical Office Information Form	Form #3	Medical Office Information Form

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	1,950	0	0	1,950	0	0
Annual Time Burden (Hours)	816	0	0	816	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new information collection request.

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Annual Cost to Federal Government: $310,000

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 02/13/2012

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